01 Aug Seven Years On

Working at St Andrews hospital
during the later part of the afternoon you’ll sometimes hear the wonderful
sound of the All Saints Church choir drifting down on the breeze as they
rehearse in the church. The sound of an African church choir is something
difficult to describe. Rather than having a conductor’s baton to follow, a
Malawian choir will keep time with each other by dancing – stepping lightly
from one foot to the other, swaying their hips and swinging their arms to the
same tempo. When their voices break out into song it is rich, soulful and joyful.
I would almost say it is worth travelling to Malawi just to hear them.

My name is Philip Delbridge. In
2011 I spent a month visiting St Andrews hospital as a medical student on
elective. These days I’m a registrar (a middle grade doctor) specialising in
Emergency Medicine. So I normally work in the UK’s busy A&E departments.

Earlier this year, at the end of
July, I travelled back to Malawi with my wife, Kate, who is also a doctor. It
had always been my intention to return to the country after I’d fallen for it
as a student. Luckily, my wife also loves Malawi and has worked here in the
past. We live in the south – in Blantyre, the country’s largest city (although
the capital is Lilongwe) – where we’re both working as volunteer doctors.

Since returning to Malawi, it has
been in my mind to revisit St Andrews. Recently, I had the opportunity to go
and do just that. This is a report of my observations, going back to St Andrews
after seven years.

WHAT’S CHANGED?

When I arrived at St Andrews in
August of 2011, the Forsyth Operating Theatre and Surgical Ward had just been
added to the hospital. Since then so much more has been done to expand the
facility. There is a new Paediatric wing, which has also inpatient NRU
(Nutritional Rehabilitation Unit) beds. The old Paediatric ward has been taken
over by the expanded male and female adult wards. The Shrewsbury School Eye
Clinic has been added, where Ophthalmologist Mr Amos Nyaka performs monthly
operating lists. Additionally, there is a new section of the hospital for the
Accountancy and Human Resources teams as well as a large Pharmacy storeroom.
All of this is new to me. The Pharmacy is well stocked and well organised, a
stark contrast to many other hospitals in the country (and I’ve worked at some
of them) where medication is often in short supply and poorly organised. All of
this progress has been made possible thanks to the kind support of all of Medic
Malawi’s followers.

Returning to the hospital, I was
delighted to see that some old friends were still working there. Mr Peter
Minjale, the lead Clinical Officer, was Medical Director of the hospital when I
was there in 2011. He’s a lovely man who has been working diligently at St
Andrews for such a long time now. All the staff at the hospital still look up
to him, referring to him as ‘Chief’, which is a very Malawian way of showing
deference to a respected individual.

One of the changes that struck me
about St Andrews hospital and also other hospitals in the country is the
changing demographic of patients we are seeing. When I was here seven years
ago, malnourished children made up a significant amount of our workload.
Thankfully, this situation is changing. Projects like the NRU at St Andrews are
beginning to make an impact and malnutrition seems to be less significant. Much
of the work on this front has been moved out into the communities where the aim
is to improve the prospects of at-risk children before they get to that stage
of severe malnourishment that requires admission to hospital.

Life expectancy in Malawi has
been on the increase over recent years, which is excellent news. But just like
in the UK, where a rising population of elderly people creates challenges for
the NHS, the rising number of middle-aged and elderly Malawians brings different
healthcare challenges and it is something that the country’s healthcare system
is not yet equipped to deal with. In the UK, if you suffer from a long-term
health condition such as High Blood Pressure or Diabetes, you will normally be
able to access your GP or a Practice Nurse who can help you manage the
condition, either with advice, life-style changes or through medication. In
Malawi the Primary Healthcare is simply not in place to manage these sorts of
problems and the availability of medicine such as Insulin, to control Diabetes,
is not there. As a result, patients with chronic conditions such as Diabetes
and High Blood Pressure often go untreated, which leads to their condition
getting out of control. This can result in serious complications such as
Strokes and Heart Attacks as well as other emergencies. The hospital staff at
St Andrews are recognising this pattern as well and during my time with them I
was asked to do some teaching on subjects such as Hypertensive Emergency, a
condition where blood pressure spirals out of control, or Diabetic
Ketoacidosis, where poisoning of the blood occurs as a result of uncontrolled
Diabetes. These sorts of cases are very much on the rise in Malawi.

Another factor in all of this,
which is rather interesting, is that it is desirable in Malawi to be big. In
the West, the stereotypical portrayal in the media of an attractive individual
(especially a woman) is usually someone slim. This is what we’re meant to find
appealing and indeed many people do. In Malawi it’s very different. Being big
is associated with wealth and strength and good health. Within living memory
Malawi has experienced food crises. The years 2002 & 2005 were particularly
bad but also as recently as 2012-2013 there were significant shortages of food
in some parts of the country. So it’s perhaps understandable that a Malawian
might like the idea of a potential partner who carries a bit of weight on them.
The other aspect is HIV. This disease still has a certain amount of stigma and
fear associated with it. The thinking is that HIV normally makes you lose
weight and become skinny, so if someone is fat they’re unlikely to have the
virus. Indeed, there is a certain amount of truth to this (although for
patients who are on effective treatment weight loss should be less of a
problem).

MADALITSO

In Malawi, the hot season usually
reaches its peak around October and November. These months bring vivid colours
in the flora of the country – notably the scarlet ‘Flame’ trees, the
purple-flowering ‘Jakaranda’ trees and the multi-coloured ‘Candelabra’ trees.
Now that we’re moving into December we’ve seen the dry season coming to an end
and the arrival of the rainy season, which is heralded by characteristically
spectacular thunderstorms. Once the rains set in the landscape is transformed.
Dry and dusty terrain turns to lush green as the grass grows tall and the
skeletal Baobab trees break out in leaves.

This is also a very busy time for
the Malawian people. Only 3% of the Malawian population live in cities. The
remainder of the country’s 18.6 million people live in rural areas,
predominantly in small villages. The vast majority of these people are farmers
and in fact even the city-dwellers often have a plot of land in the countryside
where they can grow their maize, which is the staple crop of the nation. With the rains, the people are hard at work
tilling the land and planting their crops. There are no tractors to speak of so
it all has to be done by hand and much of the work is carried out by women. A
simple hoe is all they use to work over the soil and break it up. After
spending an afternoon working over the garden at the AMAO orphanage in this
way, I can say from first-hand experience how tough going it is.

Nobody wants to be ill at any
time but this is perhaps the worst time of year for a Malawian to become
unwell. Should they be unable to plant their land in a timely fashion they risk
going hungry for the rest of the year. It’s a real worry for many of the
villagers around Mtunthama, where the majority of St Andrew’s patients come
from. As a result, the number of inpatients at the hospital is currently lower
than average with people desperate to stay at home to get on with the required
work. However, the worry for clinicians is that people will leave it too late
before seeking help when they do fall ill.

Madalitso (the name means
‘blessings’ in Chichewa), a five-year-old boy I saw on the paediatric ward with
his mother, had been admitted with severe Malaria just a couple of days
earlier. Malaria is a parasitic infection of the blood. Mosquitos spread the
parasites from person to person. It is still one of the most common illnesses
you’ll come across in Malawi. In fact, pretty much every Malawian will get the
infection more than once over the course of his or her lifetime. Children are
more severely affected. By the time a Malawian reaches adulthood they will
normally have built up a degree of immunity to the disease. Whereas most adults
in Malawi experience only a mild illness when the infection strikes, children
don’t yet have this tolerance to the disease.

In Madalitso’s case, the Malaria
was bad enough to cause a severe anaemia as the parasites had attacked his
blood cells and caused them to break down. Anaemia is a common complication of
Malarial infection. Although he was really very ill, thankfully Madalitso
started to improve after St Andrews provided him with treatment including
intravenous anti-Malarial medication and a blood transfusion. Two days later
and he was conscious and able to sit up in his bed. Our plan was to recheck his
haemoglobin levels (haemoglobin is the iron-based molecule in red blood cells
that carries oxygen). On admission he had less than half the normal amount of
haemoglobin. However, his mother was impatient. She wanted to take Madalitso
home. There was work to be done in the fields.

In such cases the clinicians at
the hospital try to be sensitive to the needs of the people they’re looking
after. They know the pressures that Malawians face. Madalitso probably needed
one or two more days in hospital ideally but that might mean his mother
wouldn’t be able to get her crops in the ground at the right time, putting the
family at risk in the year ahead. So a compromise was reached. We would check
his haemoglobin levels first thing that day and monitor him over the course of
the morning. If he remained stable and the results were satisfactory he could
be discharged with some iron tablets to help his body recover the lost blood
and some oral anti-Malarial medication to get rid of the last of the parasites.
He went home later that day.

The other strength of a charity
like Medic Malawi is the way in which it passes responsibility back to the
local Malawian people. The charity and the local leadership maintain a
discussion about how funding is allocated. The infrastructure that Medic Malawi
helps to fund is run locally, not overseen from the outside. The onus is on the
community to make the most of what is provided. These sorts of arrangements
tend to work better than when a charity comes in and tries to dictate
everything. To my mind, a charity that works alongside local communities in the
way that Medic Malawi does is the right approach.

Malawi is a country full of potential. It feels like a work
in progress, somewhere unfinished. It is a country full of charm and beauty but
also grief and loss. Sadly, it remains one of the poorest in the world but
there are steps forward being made. In supporting Medic Malawi, you are a part
of that process, and that is surely a wonderful thing.